See also
Acute pain management
Autism and developmental disability: Management of distress/agitation
Communicating procedures to children
Procedural sedation
Key points
- Ensure that every step is taken to protect children from unnecessary healthcare-induced trauma and distress, especially those who will need ongoing medical care
- Minimise distress by keeping the child with a carer, allow them to adopt the most comfortable posture and reduce external stimuli
- Unwell children may be at risk of deterioration if they are upset, sedated or repositioned
- Tailor assessment and management to the specific needs of the child. Consider specific strategies for neurodiverse children
Background
A sick child may deteriorate with handling
Increased distress in an unwell neonate, infant or child can:
- Increase heart rate, respiratory rate and blood pressure
- Cause deoxygenation (especially in neonates)
- Contribute to a deterioration in the child’s condition from moderate to severe, or severe to critical
Assessment
When clinically appropriate, allow the child to settle quietly on carer’s lap in a position of their choice, and enter the child’s space slowly and quietly, without rushing towards them
History
- When taking a history from the child or carer, speak softly and calmly, sit or kneel or to position yourself at or below the height of the child
- Asking the child about their likes and dislikes can build rapport and facilitate trust eg pets, siblings, favourite toys, books, TV shows
- In younger children ask the carer what toys, books, music or videos might help to comfort the child
- Comfort, settling or coping strategies
- Previous experiences of hospital, if any, what worked well or what didn’t work well
- Use language appropriate to the child’s age and development
- History of neurodiversity
Examination
- Much of the assessment of a child can be gained from general observation, before approaching and physically examining the child
- Prioritise critical components of the examination and avoid prolonged examination
- Opportunistically perform parts of examination, with the child sitting on the lap of a carer when clinically appropriate
- Demonstrate examination on the carer or a toy before placing stethoscope, hands, otoscope on the child
- Use carer assistance where appropriate eg carer holding stethoscope in place
- Offer child choices when practical eg which arm for blood pressure cuff, which ear for temperature
- Leave the most distressing parts of examination until the end eg blood pressure, examination of the oropharynx
Management
Investigations
- Minimise investigations that are not going to affect acute management to avoid unnecessary distress
- Group interventions together
- If IV access is required, use comfort positioning, appropriate analgesia/topical anaesthetic cream and distraction techniques
- See Procedural sedation
Treatment
Approach |
Strategies |
Parent or carer
|
Keep the child with carer
Family presence should always be encouraged (unless family member is agitated and causing further distress)
Carers can also help support the child with distraction and soothing words while assisting with comfort positioning
Ensure language and cultural needs are met |
Positioning |
Allow the child to adopt the position in which they are most comfortable, if clinically appropriate
Sitting upright reduces distress by enhancing children’s sense of control, and has been shown to increase children’s level of comfort during procedures
Secure, comfort or ‘hugging’ holds should be used to assist rather than restrain the child for necessary examination or interventions (see Additional notes below)
Skin to skin or ‘kangaroo care’ can be useful for preterm and term infants, or swaddling and facilitated tucking |
Environment |
Ensure child is being treated in the most appropriate area for acuity of care with medical and nursing staff skilled in paediatric practice
Dim lighting
Reduce number of people in the room
Speak softly and calmly
Try to reduce noise and noxious stimuli eg monitor alarms and loud conversations |
Minimise intervention |
Minimise examination and investigations that are not going to impact acute management
Minimise or group cares and interventions eg observations and medications |
Provide comfort |
Use comfort techniques such as providing comforting toy or blanket, books, photos, videos, family members
Allow the child comfort feeds if safe to do so. Breastfeeding is a multimodal comfort strategy providing skin to skin contact, the comfort of sucking and rocking, and the likely transfer or endogenous opiates from breastmilk |
Distraction strategies |
Blowing bubbles, reading a story, looking at pictures, offering an animated video or interactive game
Virtual reality technology can be used if age-appropriate Utilise available services such as Child life/play/diversional therapists, occupational therapists, psychologists, music therapists, clown doctors etc |
Relaxation techniques |
Music therapy Deep breathing, tummy breathing and grounding exercises for older children Child blowing bubbles
Continuing any working self-soothing strategies
Screens may be helpful |
Consider consultation with local paediatric team when
- Clinician experienced in caring for children is required
- Advice regarding escalation of care required
Consider consultation with Child Life/play therapy (if available)
- For children presenting as anxious and distressed
- For children requiring preparation and procedural support for medical interventions
Consider transfer when
Level of care required is above that of the local hospital
For emergency advice and paediatric or neonatal ICU transfers, see Retrieval services
Parent information
Comfort Kids: toolkit for families
Children's Health QLD: Helping your child through a procedure
NSW Health: Minimising painful procedures (baby)
NSW Health: Minimising painful procedures (child)
RCH Kids Health Info: Reducing your child's discomfort
RCH Kids Health Info: Your child's hospital stay
Additional resources
A child's guide to hospital (video)
About Child Life Therapy
Comfort kids
Additional notes
Examples of positioning and comfort holds
.png "Comfort holds 1")
.png "Comfort holds 2")
.png "Comfort holds 3")
.png "Comfort holds 4")
Last updated August 2024